Citation Nr: 1752074 Decision Date: 11/14/17 Archive Date: 11/22/17 DOCKET NO. 14-00 461 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Togus, Maine THE ISSUES 1. Entitlement to service connection for a bilateral knee disability. 2. Entitlement to service connection for neurologic and biologic toxicity. 3. Entitlement to service connection for sleep apnea. 4. Entitlement to service connection for visual impairment. 5. Entitlement to service connection for a seizure disorder. 6. Entitlement to service connection for Lyme disease. 7. Entitlement to service connection for heavy metal toxicity. 8. Entitlement to service connection for human monocytic ehrlichiosis, to include Ehrlichia. 9. Entitlement to service connection for chlamydia pneumoniae. 10. Entitlement to service connection for Epstein-Barr virus. 11. Entitlement to service connection for human herpes virus 6 (HHV-6). 12. Entitlement to service connection for herpes simplex virus 1 (HSV-1). 13. Entitlement to service connection for chronic candidiasis. 14. Entitlement to service connection for a disability as a result of a vaccination injury. 15. Entitlement to service connection for immune system inflammation and dysfunction. REPRESENTATION Appellant represented by: Sean Kendall, Attorney ATTORNEY FOR THE BOARD R. Behlen, Associate Counsel INTRODUCTION The appellant served on active duty in the Air Force from May 1992 to October 1994. This matter comes before the Board of Veterans' Appeals (Board) from a July 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. As set forth above, the claims are now in the jurisdiction of the RO in Togas, Maine. In July 2015, the Board remanded the matter for additional evidentiary development and due process considerations. In the introduction portion of that remand, the Board noted that although 33 separate issues had been certified for appeal, many were symptoms of a disability or disabilities. Thus, for purposes of clarity, the Board recharacterized the issues on appeal, thereby reducing the number of issues to 18. While the matter was in remand status, in a November 2016 rating decision, the RO granted service connection for chronic fatigue syndrome with fibromyalgia, adjustment disorder with persistent anxiety, and irritable bowel syndrome, effective May 3, 2010. These grants of service connection constitute a full award of the benefits sought on appeal with respect to those claims. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Absent any indication that the Veteran has submitted a notice of disagreement with the downstream elements of initial rating or effective date, those matters are not in appellate status. Grantham, 114 F.3d at 1158 (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). In January 2017, the RO issued a Supplemental Statement of the Case (SSOC) addressing the remaining issues on appeal. The Board notes that on her January 2014 substantive appeal, the appellant requested a Board videoconference hearing. She was notified of her scheduled April 2015 hearing in a March 2015 letter. A statement from the appellant's attorney, received via facsimile three days prior to the scheduled hearing, noted that the appellant wished to cancel the video Board hearing. Thus, the Board finds that the hearing request has been withdrawn. 38 C.F.R. § 20.704(e). A review of the record shows that the RO has substantially complied with all remand instructions. The appellant and her attorney have not contended otherwise. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. The most probative evidence establishes that the appellant does not have a current bilateral knee disability for which service connection may be granted. 2. The most probative evidence establishes that the appellant does not have a current neurologic and biologic toxicity disability for which service connection may be granted. 3. Sleep apnea was not present during the appellant's active service and the most probative evidence establishes that the appellant's current obstructive sleep apnea is not caused by or the result of her active service or caused or aggravated by any service-connected disability. 4. The most probative evidence establishes that the appellant does not have a current visual impairment disability for which service connection may be granted. 5. The most probative evidence establishes that the appellant does not have a current seizure disorder for which service connection may be granted. 6. The most probative evidence establishes that the appellant does not have a current Lyme disease disability for which service connection may be granted. 7. The most probative evidence establishes that the appellant does not have a current heavy metal toxicity disability for which service connection may be granted. 8. The most probative evidence establishes that the appellant does not have a current human monocytic ehrlichiosis disability, to include Ehrlichia, for which service connection may be granted. 9. The most probative evidence establishes that the appellant does not have a chlamydia pneumoniae disability for which service connection may be granted. 10. The most probative evidence establishes that the appellant does not have an Epstein-Barr virus disability for which service connection may be granted. 11. The most probative evidence establishes that the appellant does not have a human herpes virus 6 disability for which service connection may be granted. 12. The most probative evidence establishes that the appellant does not have a herpes simplex virus 1 disability for which service connection may be granted. 13. The most probative evidence establishes that the appellant does not have a chronic candidiasis disability for which service connection may be granted. 14. The most probative evidence establishes that the appellant does not have a disability as a result of a vaccination injury for which service connection may be granted. 15. The most probative evidence establishes that the appellant does not have an immune system inflammation and dysfunction disability for which service connection may be granted. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a bilateral knee disability have not been met. 38 U.S.C. §§ 1110, 5107 (West 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2017). 2. The criteria for entitlement to service connection for neurologic and biologic toxicity have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 3. The criteria for entitlement to service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 4. The criteria for entitlement to service connection for visual impairment have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 5. The criteria for entitlement to service connection for a seizure disorder have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 6. The criteria for entitlement to service connection for Lyme disease have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 7. The criteria for entitlement to service connection for heavy metal toxicity have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 8. The criteria for entitlement to service connection for human monocytic ehrlichiosis, to include Ehrlichia, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 9. The criteria for entitlement to service connection for chlamydia pneumoniae have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 10. The criteria for entitlement to service connection for Epstein-Barr virus have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 11. The criteria for entitlement to service connection for human herpes virus 6 have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 12. The criteria for entitlement to service connection for herpes simplex virus 1 have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 13. The criteria for entitlement to service connection for chronic candidiasis have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 14. The criteria for entitlement to service connection for a disability as a result of a vaccination injury have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). 15. The criteria for entitlement to service connection for immune system inflammation and dysfunction have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) During her December 2010 Decision Review Officer (DRO) hearing, the appellant expressed displeasure regarding a 2010 VA examination, testifying that the examiner stated that her voluminous medical records were overwhelming and there was insufficient time to review any such records. However, since then, the appellant has been afforded additional VA examinations, most recently in May 2016. The May 2016 examiners thoroughly reviewed the voluminous medical evidence of record and the opinions offered clearly cite to such medical evidence. The Board finds that the medical opinions provided by the May 2016 VA examiners are well-reasoned and based upon thorough review of the appellant's voluminous medical records and examinations of the appellant. See Barr v. Nicholson, 21 Vet. App. 312 (2007). Neither the appellant nor her attorney has raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Applicable Law A. Standard of Proof The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). "It is in recognition of our debt to our veterans that society has [determined that,] [b]y tradition and by statute, the benefit of the doubt belongs to the veteran." See Gilbert, 1 Vet. App. at 54. B. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. § 1110. "To establish a right to compensation for a present disability, a Veteran must show: '(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service'-the so-called 'nexus' requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases, including arthritis and organic diseases of the nervous system, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a) (3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As set forth in more detail below, X-ray studies have shown that the appellant does not exhibit arthritis of the right or left knee. Thus, this provision is not for application. Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. §§ 1110, 1131. Thus, where the collective lay and medical evidence indicates that, fundamentally, the appellant does not have a current disability for which service connection is sought, there can be no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gilpin v. West, 155 F.3d 1353, 1356 (Fed. Cir. 1998). III. Analysis The Board has reviewed all of the evidence in the appellant's claims file. In this regard, the Board notes that, although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, all of the extensive evidence of record. Indeed, it has been held that while the Board must review the entire record, it need not discuss each piece of evidence in rendering a decision. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007); Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); see also Dela Cruz v. Principi, 15 Vet. App. 143, 148-49 (2001). A. Competency Along with military, private, and VA medical records, the claims file includes timelines prepared by the appellant regarding her observed symptomatology and her medical appointments. During the March 2010 DRO hearing, the appellant reported that she was an air medical technician while on active duty, and performed minor surgeries, administered vaccines, and administered IV's. She stated that she has also worked in emergency rooms, worked as a medical assistant, performed medical billing and coding, and has done a great deal of her own medical research regarding her symptomatology. The Board has considered the appellant's lay history of symptomatology related to her claimed disorders throughout the appeal period. She is competent to report such symptoms and observations because this requires only personal knowledge as it comes through an individual's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board notes the appellant's reported experience in the medical field. Questions of competency notwithstanding, it finds that the opinions of the May 2016 VA examiners are entitled to greater probative weight because the objective examiners examined the appellant, thoroughly reviewed the voluminous medical evidence of record, considered the appellant's reported medical history and contentions, and have noted experience in rheumatology and other clinical practices. B. Private Medical Opinion An April 2010 letter from Dr. G.S.R. is of record. The appellant's military and civilian records from May 1992 to 2010 were reviewed. Dr. G.S.R. opined that the appellant's past health issues and current symptomatology were the same, including chronic fatigue, myalgias, muscle weakness, intolerance to exercise, gastrointestinal symptoms, low-grade fevers, chills and sweats, frequent headaches, migratory joint pains, and sleep disturbance due to obstructive sleep apnea. Persistent neurological symptoms including seizure-like activity, shooting and stabbing pains, visual impairment, neurocognitive difficulties, anxiety, and hypervigilance were also noted. Dr. G.S.R. opined that the symptoms, and the chronicity and patterns of relapse thereof, are typically seen in tick-borne infections. He noted that the appellant was not tested for tick-borne infections during active service, but negative ELISA testing was reported. He explained that ELISA was a screening tool, but not a good diagnostic test. Dr. G.S.R. stated that March 2010 Lyme Dot-Blot challenge urine results were positive and highly diagnostic for Lyme disease. He also noted a positive Ehrlichea test, and stated that Ehrlichea was an illness commonly found in the Lonestar tick, which is endemic to the central southern United States, where the appellant underwent basic training in 1992. He also noted that the appellant tested positive for Epstein-Barr virus, HHV-6, Candida albicans, and Chlamydia pneumonae. He stated that the appellant's lymphocytes showed a markedly lowered immune reactivity, and noted that the appellant was given a high number of vaccinations in a short period of time while on active duty. He opined that these vaccinations contributed to the diminishing of her immune responsiveness, noting that the appellant was prescribed antibiotics for much of her active service. He opined that the identified disorders were more likely than not incurred during and aggravated by the appellant's active duty. He also opined that the appellant's current diagnoses of Lyme disease, Ehrlichea, immune dysfunction syndrome, and neurologic and biologic toxin were more likely than not incurred and aggravated during her active service. In May 2016, Dr. S.H.P. examined the appellant and opined that it was less likely than not that the appellant had Lyme disease, as diagnosed by Dr. G.S.M., which was caused by or incurred in active service. Dr. S.H.P. thoroughly reviewed the appellant's medical records and observed that, during the appellant's protracted multi-symptom illness, there was no diagnosis of a systemic infection, including a tick-borne infection. Rather, there was no unifying medical diagnosis in the service treatment records. It was noted that the appellant's skin condition was diagnosed as pityriasis lichenoidis acuta by biopsy. Dr. S.H.P. observed photographs and dermatological evaluations, which revealed that the appellant had small, diffuse macular lesions which are not characteristic of the large, confluent rash expected of Lyme disease. The treating dermatologists did not diagnose her rash as Lyme disease. Service treatment records were negative for a diagnosis of Lyme disease. Dr. S.H.P. observed that Dr. R.A.S., a VA infectious disease specialist, reviewed the question of whether the appellant had Lyme disease in 2010. He concluded that the appellant did not meet the clinical or serologic criteria for Lyme disease at any point previously. Therefore, she did not meet the criteria for acute Lyme, late Lyme, or post Lyme syndrome. Dr. P.G., a VA rheumatology specialist, concurred that there was no evidence to support a diagnosis of chronic Lyme disease. Dr. S.H.P. observed that Dr. G.S.R. stated that the appellant's urine test "was positive in three out of three samples, which is highly diagnostic for Lyme disease." However, Dr. S.H.P. noted that, according to the Centers for Disease Control and Prevention (CDC), "capture assays for antigens in urine" are specifically listed as unvalidated tests. It was also noted that Dr. G.S.R. based his diagnostic opinion, at least 15 years after the initial condition, on the basis of such laboratory testing performed more than 15 years after the initial condition. Thus, Dr. S.H.P. opined that Dr. G.S.R.'s diagnosis of Lyme disease was negated by the two Board-certified internists who specialize in the field of Lyme disease and that such was less likely than not incurred in or caused by her active service. Likewise, Dr. S.H.P. observed that Dr. G.S.R. based his diagnosis of Ehrlichiosis Chaffeensis on 2009 and 2010 blood work for an illness that occurred more than 15 years ago because "this type of illness is commonly found in the Lonestar tick, which is endemic to areas of the central southern United States" where the appellant underwent basic training. However, the 2009 and 2010 samples returned conflicting results. Dr. R.A.S. was noted to conclude in 2010 that, because the serologies were performed at different labs with different results, it suggested that serologies were unreliable. Service treatment records were negative for a diagnosis of Erhlichiosis while the appellant was stationed in Texas. Service treatment records included a complaint of a food-borne illness while in Texas. Onset of increased pityriasis lichenoidis acuta and fatigue symptoms occurred while she was stationed in New York, months after the appellant was in Texas. Dr. S.H.P. observed that the appellant's lab results while on active duty did not include characteristic findings of human ehrlichial infection, such as anemia, thrombocytopenia (low platelets), leukopenia (low white count), abnormal liver, or abnormal kidney function. Dr. S.H.P. concluded that Dr. G.S.R.'s diagnosis of human Erhlichiosis infection was simply based on two conflicting test samples obtained 15 years after presumed tick exposure and the fact that a particular species of tick can be located in Texas; thus, the diagnosis was loosely speculated. Dr. S.H.P. therefore concluded that it was less likely than not that the appellant had Erlichiosis which was caused by or incurred in active service. Dr. S.H.P. opined that it was less likely than not that the appellant's vaccination-induced "lowered immunity," as diagnosed by Dr. G.S.R., was caused by or incurred in active service. Dr. S.H.P. noted that the appellant received numerous vaccinations in short succession while on active duty. Dr. G.S.R. diagnosed "weakened immune system," based on fluorescene-activated cell sorting (FACS), due to a high number of vaccinations, which contributed to the diminishing of her immune responsiveness. However, Dr. S.H.P., a rheumatologist and internist who is familiar with such laboratory tests and has personally performed them, explained that FACS is not a test for immune responsiveness, as claimed by Dr. G.S.R. Rather, FACS sorts out cells with various cell surface markers called cluster of differentiation (CD), in order to approximate what cell populations are present in the blood sample on a particular day. Dr. S.H.P. explained that it is not a test for immune response, the sample was obtained from the appellant 15 years following the presumed injury by vaccination, and the results can be affected by a multitude of factors, including the appellant's physical condition the day of the blood draw and laboratory error. Dr. S.H.P. stated that the test results can no more be traced to in-service vaccinations than childhood vaccinations or the appellant's breakfast the day of the blood draw in question. Further, the vaccinations the appellant received were noted to be approved by the Food and Drug Administration (FDA). Dr. S.H.P. opined that Dr. G.S.R.'s diagnosis of lowered immune responsiveness was based on a lack of understanding of the test. Dr. S.H.P. also stated that the thesis that "vaccinations cause lowered immunity" is against all scientific evidence. Dr. S.H.P. also opined that it was less likely than not that the appellant had Epstein-Barr virus, HHV-6, candida, and chlamydia pneumoniae infections, as had been diagnosed by Dr. G.S.R., which were caused by or incurred in service. It was noted that all of these were diagnosed based on blood tests performed between 1999 and 2010 which showed positive IgG levels, well after the appellant's active service. Dr. S.H.P. explained that, without appropriate context, these tests are not interpretable because they simply show exposure to an organism at an uncertain point in time. Without signs and symptoms of an infection caused by these organisms, antibody tests in and of themselves are not diagnostic of an infection. Service treatment records were negative for signs or symptoms of any of these organisms. Dr. G.E.W. also examined the appellant and thoroughly reviewed all of the medical evidence of record in May 2016. Dr. G.E.W. stated that he reviewed Dr. S.H.P.'s opinions and cited evidence regarding Lyme disease, human monocyte ehrlichiosis, including Ehrlichia, vaccination injury/immune system inflammation, chlamydia pneumoniae, Epstein-Barr virus, human herpes virus 6, herpes simplex virus 1, and chronic candidiasis, and concurred with Dr. S.H.P.'s opinions as written. With respect to the appellant's claimed vaccination injury, Dr. G.E.W. also noted that there was no evidence of record that the appellant had ever been diagnosed with esophageal candidiasis or any other opportunistic infections or malignancies of the types that are generally associated with immune system dysfunction. Based upon Dr. S.H.P. and Dr. G.E.W.'s thorough reviews of the medical evidence of record, thorough medical rationales, and discussion of the inconsistencies in Dr. G.S.R.'s April 2010 medical opinion and Dr. G.S.R.'s reliance on remote medical testing and medical testing that the CDC considers unvalidated for the purposes such were relied upon by Dr. G.S.R., the Board finds that Dr. G.S.R.'s medical opinions are entitled to low probative weight. C. Separation Examination The appellant's July 1994 separation examination was essentially normal. Pityriasis lichenoidis and keratosis pilaris were noted. On her July 1994 Report of Medical History, the appellant denied eye trouble, arthritis, rheumatism, or bursitis, bone, joint, or other deformity, "trick" or locked knee, and periods of unconsciousness. She reported swollen or painful joints, chronic or frequent colds, skin diseases, frequent indigestion, broken bones, recent gain or loss of weight, frequent trouble sleeping, and depression or excessive worry. The examining physician noted a 1988 stress fracture of the left tibia, chickenpox in April at the age of 20, and a May 1993 diagnosis of pityriasis lichenoidis chronica skin disease. Swollen and painful joints were reported from September 1993 to January 1994. Tests for rheumatoid arthritis were negative; she was treated for joint pain as viral syndrome. She was diagnosed with keratosis pilaris on back and arms in December 1993. The Board notes that the appellant is already service-connected for pityriasis lichinoids, chronic, associated with keratosis pilaris rubra. D. Entitlement to Service Connection 1. Bilateral knee disability The appellant contends that she developed a bilateral knee disability, not due to any in-service sprain or strain, but due to chronic Lyme disease. Service treatment records record complaints of knee pain. "Trick" knee, locked knee, arthritis, rheumatism, and bursitis were denied, while "swollen or painful joints" was endorsed at separation. A 1988 pre-service stress fracture of the left tibia was noted. Tests for rheumatoid arthritis were negative; she was treated for joint pain as viral syndrome. The appellant was afforded a VA examination for her bilateral knees in May 2016. The claims file was reviewed. She was diagnosed with bilateral knee pain associated with fibromyalgia, first diagnosed in 1999. The appellant reported developing bilateral knee pain and swelling during service. Sprains and strains were denied, although a January 1994 clinical note showed possible patellofemoral pain syndrome. Service treatment records were negative for any chronic knee pain treated in service that was the result of injury and strain. The appellant contended that her knee pain was the result of chronic Lyme disease. The examiner noted that testing for rheumatoid and other inflammatory arthritis has been well-documented as negative. It was noted that the appellant was service-connected for fibromyalgia, which includes migratory joint pain as symptoms. The appellant had not undergone knee surgery. The examiner opined that it was less likely than not that the appellant had a current bilateral knee disability which was caused by or incurred in service. There was no evidence of record to warrant a diagnosis of a bilateral knee disability that is separate from the migratory joint pain that is an integral part of her already service-connected fibromyalgia. Knee examination was normal; and evaluation for rheumatoid and inflammatory arthritis was repeatedly negative. The appellant herself did not contend that it was due to any service-connected sprain or strain; rather, the appellant contends that she has a knee disability due to chronic Lyme disease, which has not been established as a diagnosis, per the May 2016 VA examinations and opinions. Upon weighing the evidence, the Board finds that the preponderance of the evidence is against the appellant having a current bilateral knee disability that was caused by or incurred during active service. The May 2016 VA examiner's opinion was based upon examination of the appellant and thorough review of the voluminous medical records in the claims file. There is no probative medical evidence to support the conclusion that the appellant has a current bilateral knee disability. Symptomatology of knee pain, attributable to fibromyalgia, is present. However, this pain is already contemplated in the appellant's 100 percent rating for chronic fatigue syndrome with fibromyalgia from May 3, 2010, and in the appellant's 40 percent rating for fibromyalgia prior to May 3, 2010. As discussed below, service connection for Lyme disease is denied; thus, even if there were evidence that appellant did have a knee disability due to Lyme disease, service connection could not be granted because Lyme disease is not service-connected. Presumptive service connection is not for application because there is no probative evidence that the appellant has an enumerated knee disability, such as arthritis. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Neurologic and biologic toxicity The appellant was afforded a VA examination in May 2016 for claimed neurological and biological toxicity. The claims file was reviewed. The appellant did not have a peripheral nerve condition or peripheral neuropathy. The appellant reported migratory shooting pains down all extremities. Paresthesias and numbness, which do not coincide in time with the pain, were reported. Localized extremity weakness was denied. Muscle weakness related to fibromyalgia was noted. The appellant contended that her symptoms were due to "Lyme disease of the brain." She reported that she had not been diagnosed with peripheral neuropathy. Examination revealed that the appellant had no symptoms attributable to any peripheral nerve condition. Neurologic and biologic toxicity was not diagnosed. With respect to neurological and biological toxicity, Dr. G.E.W. noted that the appellant contends that this claim encompasses her claim for seizure disorder. As noted in the examination report, a diagnosis of seizure disorder had not been established. The appellant contended that neurologic and biologic toxicity was due to Lyme disease, for which a diagnosis has not been established per examination and opinion by the other May 2016 examiner. Upon weighing the evidence, the Board finds that the preponderance of the evidence is against the appellant having neurologic and biologic toxicity attributable to her active service. Although Dr. G.S.M. provided a positive opinion, the May 2016 VA medical examinations did not result in a diagnosis of neurologic and biologic toxicity. As discussed above, the Board finds the May 2016 VA examination report to be entitled to greater probative weight than Dr. G.S.M.'s opinions. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 3. Sleep apnea In April 2010, Dr. G.S.R. opined that the appellant's sleep disturbance, which began in service, was due to sleep apnea. Disability Benefits Questionnaires (DBQ) completed by Dr. G.S.R. in March 2015, however state that the appellant's sleep disturbances were due to fibromyalgia and chronic fatigue syndrome. These contradictions reduce the probative value of Dr. G.S.R.'s opinions with respect to the onset of sleep apnea. After examining the appellant in May 2016, Dr. G.E.W. opined that the appellant's sleep impairment was a symptom of both her service-connected adjustment disorder with anxiety and her chronic fatigue syndrome with fibromyalgia. It was noted that, although the appellant had been diagnosed with obstructive sleep apnea, it has been clearly documented that her difficulty sleeping is not related to obstructive sleep apnea. Dr. G.E.W. also observed that, while symptoms of sleep disturbance and fatigue were noted in the service treatment records, such records are negative for any consideration or suspicion of sleep apnea during service. Sleep apnea was not diagnosed until five years after separation. With respect to whether sleep apnea is proximately due to or aggravated by service-connected fibromyalgia, Dr. G.E.W. explained that there is no known pathophysiologic mechanism by which any service-connected disability, to include fibromyalgia, chronic fatigue syndrome, or irritable bowel syndrome, would cause the obstruction of the upper airway which itself causes sleep apnea. The Board finds that the preponderance of the evidence is against the appellant's sleep apnea being caused by or incurred in during her active service or proximately due to or aggravated by the appellant's fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, or any other service-connected disability. Dr. G.E.W.'s opinion is entitled to great probative weight as it is well-reasoned and based upon thorough review of the claims file. The medical evidence of record indicates that the appellant was not diagnosed as having sleep apnea until many years after her active service and that her symptoms of sleep disturbance were associated with her chronic fatigue syndrome and adjustment disorder with anxiety, for both of which she is service-connected. The Board notes that the appellant is already receiving compensation for her sleep disturbance symptoms from her service-connected chronic fatigue syndrome with fibromyalgia and adjustment disorder with persistent anxiety. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 4. Visual impairment The appellant contends that her visual impairment, to include double vision or astigmatism, was caused by, incurred in, or aggravated by, her active service. The appellant declined an examination for her visual impairment claim in May 2016. Under 38 C.F.R. § 3.655, when a claimant fails to report for a requested medical examination in conjunction with an original compensation claim, the claim shall be based on the evidence of record. A September 1997 letter from Dr. L.D.D. includes an opinion that the appellant's history of two episodes of visual blurring with nausea and dizziness were likely symptoms of menstrual migraines. In April 2010, Dr. G.S.R. opined that the appellant's neurological symptoms of visual impairment were typically seen in tick-borne infections. However, as discussed infra and supra, service connection is denied for Lyme disease and other tick-borne infections, and Dr. G.S.R.'s medical opinion is entitled to minimal probative weight. In any event, in June 2010, the appellant denied tick exposure history as far as she could recall. Service treatment records are negative for complaints of insect bites while stationed in Texas. The appellant reported going to sick call in August 1994 for insect bites while stationed in New York. The appellant's service treatment records, including the report of her enlistment medical examination, indicates she requires corrective lenses for vision. The Board notes that it is well established that a refractive error, including astigmatism, is not a disability within the meaning of applicable regulations providing for payment of VA disability compensation benefits. 38 C.F.R. §§ 3.303, 4.9. To the extent that any visual symptomatology is due to service-connected fibromyalgia or chronic fatigue syndrome, the appellant is already being compensated for such. There is simply no competent medical evidence of record that the appellant experiences a current visual impairment which was caused by or incurred during her active service, or that the appellant was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90. Thus, entitlement to service connection for visual impairment is denied. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 5. Seizure disorder March 2002 letters from Dr. J.D. and Dr. K.B.K. note that the appellant first experienced episodes manifested by sensations of muscles being relaxed, an inability to concentration, a fearful sensation, and nausea, in May 1998. Triggers include strong odors, loud noises, sugary foods, fatigue, and the perimenstrual period. There were no other symptoms to suggest seizures. Dr. K.B.K. opined that these events may represent complex partial seizures. The appellant was afforded a VA examination in May 2016 for seizures and epilepsy. The claims file was reviewed. The appellant reported episodic spells of feeling "zoned out" with a sense of less awareness, an inability to concentrate, and a feeling that everything is muffled. Loss of consciousness and involuntary movements were denied. She reported a possible partial complex seizure diagnosis in 2002, but it was never proven. A 1998 neurology consultant doubted the presence of true seizures. The appellant had not taken anticonvulsant medications. The appellant contended that her claimed seizures were the result of "Lyme disease in the brain." The appellant had no findings, signs, or symptoms attributable to a seizure disorder or epilepsy activity. 2001 MRI and EEG studies were normal. Dr. G.E.W. opined that it was less likely than not that any seizure disorder was caused by or incurred during active service because there was no convincing evidence from the examination, or in the medical records, that the appellant had a seizure disorder. Neurology consults only gave a possibility of partial complex seizures, EEG was normal, and anticonvulsant medications had never been required. Service treatment records were negative for any history or suspicion of seizures. Even if seizure disorder had been diagnosed, actual seizures are not a known component of or known to be caused by fibromyalgia, chronic fatigue syndrome, or any of the appellant's other service-connected disabilities. With respect to the appellant's contention that her "seizure disorder" was due to neurologic and biologic toxicity due to Lyme disease, that had not been established as a diagnosed condition per the May 2016 infectious disease VA examination and opinion. The Board has considered Dr. K.B.K.'s opinion that the appellant's claimed symptoms "may" represent complex partial seizures and the appellant's report of a "possible" partial complex seizure diagnosis in 2002. It is well established that medical opinions that are inconclusive in nature do not provide a sufficient basis upon which to support a claim. See e.g. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (finding doctor's opinion that "it is possible" and "it is within the realm of medical possibility" too speculative to establish medical nexus); Goss v. Brown, 9 Vet. App. 109, 114 (1996) (using the words "could not rule out" was too speculative to establish medical nexus); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (holding that a physician's statement that a service-connected disorder "may or may not" have prevented medical personnel from averting a Veteran's death was not sufficient). Given the applicable standard of proof, the Board finds that Dr. K.B.K's opinion and the appellant's reported "possible" seizure diagnosis are insufficient to support an award of service connection and certainly do not outweigh the VA medical opinion cited above. The Board therefore finds that the preponderance of the evidence is against the claim of entitlement to service connection for seizure disorder. The May 2016 examiner noted that there was no convincing evidence that the appellant had a seizure disorder which was causally related to service or a service-connected disability. The Board assigns this opinion great probative weight. It was based upon a thorough examination of the appellant, consideration of her reported medical history, and a review of the voluminous medical evidence of record. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 6. Lyme disease In June 2010, the appellant denied tick exposure history as far as she could recall. Service treatment records are negative for complaints of insect bites while stationed in Texas. The appellant reported going to sick call in August 1994 for insect bites while stationed in New York. The appellant was afforded a VA examination in May 2016 for Lyme disease. The claims file was reviewed. Dr. S.H.P. opined that it was less likely than not that the appellant's diagnosis of Lyme disease by Dr. G.S.R. was caused by or incurred in active service. The appellant was stationed in San Antonio, Texas, from May to September 1992. Her service treatment records noted a July 1992 food-borne illness. Service treatment records were negative for a tick-borne illness, such as Lyme disease or Erhlichiosis Chaffeensis. The appellant's own historical report of her medical history from May to September 1992 is likewise negative for tick-borne illness. The appellant experienced a protracted illness beginning in February 1993, when she was diagnosed with acute sinusitis and treated with antibiotics. Significant skin lesions, increased fatigue, and other systemic symptoms were discovered during the course of treatment. However, the appellant's multisystem illness was not diagnosed as a systemic infection including a tick-borne infection. The examiner noted that there was no unifying medical diagnosis in the service treatment records. The skin lesions were ultimately diagnosed as pityriasis lichenoidis acuta by biopsy. Dr. S.H.P. reviewed photographs in the service treatment records and the reports of numerous dermatological evaluations of the appellant, all of which revealed that the skin lesion were small diffuse macular lesions which are not characteristic of the large confluent rash expected of Lyme disease. He noted that the appellant's treating dermatologist did not recognize the rash as that of Lyme disease. No diagnosis of Lyme disease was established during her active service. A biopsy did not lead two dermatologists and medical physicians to consider Lyme disease as a cause of her skin disorder. The Boston VA Medical Center (VAMC) infectious disease specialist was noted to have opined in 2010 that the appellant did not meet clinical or serological criteria for Lyme disease at any point previously, and therefore did not meet the criteria for acute Lyme, late Lyme, or post Lyme syndrome. A Boston VAMC rheumatology specialist also concluded in 2010 that there was insufficient evidence to support a diagnosis of chronic Lyme disease. It was noted that Dr. G.S.R. relied on capture assays for antigens in urine, performed 15 years after the fact, to diagnose Lyme disease. Dr. S.H.P. explained that the Center for Disease Control (CDC) specifically describes these as unvalidated tests, and that Dr. G.S.R.'s treatment plans are not standard of care treatments for Lyme infections. It was also noted that the 2010 VA infectious disease and rheumatology specialists both came to the opposite conclusion as Dr. G.S.R. In May 2016, Dr. G.E.W. independently reviewed the evidence and Dr. S.H.P.'s medical opinion and concurred. Upon weighing the evidence, the Board finds the May 2016 VA medical opinion and the 2010 VA medical opinions to be entitled to great probative weight. These negative opinions outweigh the positive opinion by Dr. G.S.R., particularly because the May 2016 opinion was based upon a thorough review of all of the evidence of record and provided a well-reasoned rationale as to why the appellant did not have Lyme disease which was incurred in or caused by her active service. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 7. Heavy metal toxicity The appellant was afforded a VA examination in May 2016 for claimed heavy metal toxicity. The claims file was reviewed. The examiner opined that it was less likely than not that any heavy metal toxicity was caused by or incurred in service. The appellant provided no documentation of any heavy metal toxicity. The only test result showing any abnormality is a urine toxicity screen from January 2010 showing a mild elevation in gadolinium, which is likely expected as the appellant had had an MRI scan with gadolinium contrast. It likely did not represent a true toxic exposure. Further, the appellant stated during the examination that she no longer believes she suffers from any heavy metal toxicity and is no longer concerned about the claim. Based on the record, the Board finds that there is no competent evidence that the appellant has a current disability of heavy metal toxicity. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 8. Human monocytic ehrlichiosis, to include Ehrlichia As discussed above, Dr. G.S.R.'s April 2010 positive medical opinion regarding human monocytic ehrlichiosis, to include Ehrlichia, is entitled to low probative weight. A June 2010 VA clinical note states that two separate ehrlichiosis serologies were performed at two laboratories in 2009 and 2010 with inconsistent results, which suggested that serologies were unreliable. The appellant was afforded a VA examination in May 2016. The claims file was reviewed. Dr. S.H.P. opined that it was less likely than not that the appellant's had ehrlichiosis, as diagnosed by Dr. G.S.R., which was caused by or the result of her active service. As explained above with respect to Lyme disease, Dr. S.H.P. noted that the appellant's service treatment records were negative for a tick-borne infection while stationed in Texas. The appellant's own records of illness are likewise negative. It was noted that Dr. G.S.R. diagnosed Ehrlichiosis Chaffeensis based on blood work performed in October 2009 and March 2010 for an illness Dr. G.S.R. believes occurred more than 15 years prior. It was noted that the October 2009 sample was positive for E Chafeensis IgG, while the March 2010 sample Dr. G.S.R. himself obtained, was negative. The Boston VAMC infectious disease specialist opined in 2010 that two separate ehrlichiosis serologies performed at different labs with different results suggest that serologies are unreliable. Service treatment records are negative for a diagnosis of Erhlichiosis while the appellant was stationed in Texas. One instance of food borne illness occurred in July 1992. The onset of increased symptoms of pityriasis lichenoidis acuta and fatigue occurred beginning in February 1993, while stationed in New York. Dr. S.H.P. reviewed the appellant's lab records, noting that they were negative for characteristic laboratory findings of human ehrlichial infection while on active duty in Texas or New York, including anemia, thrombocytopenia (low platelets), leukopenia (low white count), abnormal liver tests, or abnormal kidney function tests. Service treatment records were negative for a tick bite while in Texas. It was noted that the appellant's illness while in Texas did not have the characteristics of an Erhlichiosis infection based on laboratory findings according to medical literature. Dr. S.H.P. opined that Dr. G.S.R.'s diagnosis of Erlichiosis was fundamentally loosely speculated because it was based on two contradictory laboratory studies and simply because that type of illness was commonly found in the Lonestar tick, which is endemic to areas of the central southern United States. In May 2016, Dr. G.E.W. separately reviewed the medical evidence and Dr. S.H.P.'s opinion regarding human monocyte ehrlichiosis, including Ehrlichia, and concurred with such. For the reasons discussed above, the Board finds that the preponderance of the evidence is against the appellant having a current disability of human monocytic ehrlichiosis, to include Ehrlichia. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 9, 10, 11, 12, 13. Chlamydia pneumoniae, Epstein-Barr virus, human herpes virus 6, herpes simplex virus 1, and chronic candidiasis The appellant was afforded a VA examination in May 2016 with respect to these claims. The claims file was reviewed. Dr. S.H.P. opined that it was less likely than not that the appellant had chlamydia pneumoniae, Epstein-Barr virus, human herpes virus, herpes simplex virus, and candidiasis, as diagnosed by Dr. G.S.R., which were caused by or incurred in service. All blood testing for these disorders was conducted well after separation from service, between 1999 and 2010. Dr. S.H.P. stated that, without the appropriate context, such tests cannot be interpreted as representing exposure to an organism at an uncertain point in the past. In other words, unless the appellant had signs and symptoms of an infection caused by the respective organisms, antibody tests in and of themselves are not diagnostic of an infection. Dr. S.H.P. noted that candida albicans is a fungal organism that is considered normal flora in the gastrointestinal and genitourinary tracts of humans, although it can cause infections. Candida antibodies are found in 20 to 30 percent of healthy individuals, which complicates interpretation of antibody levels. He was unable to determine the significance of antibody findings for candida albicans as specially related to an illness denoted in the appellant's service treatment records. 95 percent of the population has been exposed to Epstein-Barr virus, which can cause mononucleosis. Mononucleosis was not diagnosed during service. He was unable to determine exactly when the appellant was exposed to this very common virus, or determine the significance of an antibody finding specifically related to an illness denoted in the service treatment records. 71 percent of the population has been exposed to herpes simplex virus 1, which causes mouth or genital sores. He could not determine exactly when the appellant was exposed to this fairly common virus and could not determine the significance of an antibody finding specifically related to an illness denoted in the service treatment records. Chlamydia pneumoniae causes pneumonia, which requires specific antibiotics for treatment. Service treatment records were negative for pneumonia. He could not determine the significance of an antibody finding specifically related to an illness denoted in the service treatment records. Human herpes virus 6 does not cause symptoms in most patients if exposed during childhood, but can lead to a fairly common childhood disease known as "roseola infantum or sixth disease." If exposed in adulthood, it can lead to a mononucleosis-like virus. Service treatment records were negative for such a diagnosis. He could not determine the significance of an antibody finding specifically related to an illness denoted in the service treatment records. Dr. S.H.P. opined that the multiple diagnoses by Dr. G.S.R. were not established during the appellant's military service per her service treatment records. The laboratory tests, upon which the diagnoses were based, were performed outside of both the temporal and clinical context of her active service. Dr. G.E.W. reviewed Dr. S.H.P.'s opinion and independently reviewed the evidence cited. He concurred with Dr. S.H.P.'s opinion as written. The Board finds that the May 2016 medical opinion is entitled to great probative weight as it is well-reasoned and methodical, and is based upon thorough review of the voluminous medical evidence of record and an examination of the appellant. The preponderance of the evidence is against the appellant having a current disability of Chlamydia pneumoniae, Epstein-Barr virus, human herpes virus 6, herpes simplex virus 1, or chronic candidiasis. Again, the appellant exhibits no signs or symptoms of an infection caused by the respective organisms; antibody tests in and of themselves are not diagnostic of an infection. Even assuming for the sake of argument that the appellant was exposed to these organisms in service, absent proof of a present disability, there can be no valid claim. As the evidence preponderates against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 14 and 15. Disability as a result of a vaccination injury and immune system inflammation and dysfunction As discussed above, Dr. G.S.M.'s April 2010 opinion regarding whether the appellant's numerous vaccinations in short succession during active service caused a disability is entitled to low probative weight. The appellant was afforded a VA examination in May 2016 for a claimed "lower immunity" due to vaccination. The claims file was reviewed. Dr. S.H.P. opined that it was less likely than not that the diagnosis of vaccination-induced "lowered immunity" by Dr. G.S.R. was caused by or incurred during service. The appellant's service treatment records and her personnel records indicate that she was vaccinated against numerous diseases and viruses while on active duty. Dr. S.H.P., a rheumatologist and internist, explained that he believed that Dr. G.S.R. based his diagnosis on a March 2010 laboratory test called "fluorescence-activated cell sorting (FACS)" or flow cytometry obtained from the appellant's blood. However, Dr. S.H.P. explained that FACS is not a test for immune responsiveness, as proclaimed by Dr. G.S.R. Rather, the test sorts out cells with various cell surface markers to approximate the cell populations in a blood sample on a particular day. The data is not a test for immune response, the sample was obtained more than 15 years after the vaccinations, and the results can be affected by a multitude of factors. Dr. S.H.P. noted that FACS results can no more be traced to vaccinations during active service than to childhood vaccinations or the type of food the appellant consumed the morning of the blood draw. Dr. S.H.P. opined that Dr. G.S.R.'s diagnosis was based upon a lack of understanding of the test. It was noted that the vaccinations received were FDA-approved. There is no evidence-based medical literature that states that vaccinations "lower immune reactivity." The examiner stated that the thesis that "vaccinations cause lowered immunity" is against all scientific evidence. Dr. G.E.W. separately reviewed the medical evidence and Dr. S.H.P.'s opinion regarding vaccination injury and immune system inflammation and dysfunction, and concurred with such. He also noted that there was no evidence of record that the appellant had ever been diagnosed with esophageal candidiasis or any other opportunistic infections or malignancies of the types that are generally associated with immune system dysfunction. The Board also notes that the appellant contends that receiving multiple vaccinations in short succession damaged her immune system. Questions of her competency to opine on such matters notwithstanding, the May 2016 medical opinions are entitled to greater probative weight because they are well-reasoned, based upon thorough reviews of the medical evidence of record and examinations of the appellant, and because the rationales are based upon review of evidence-based medical literature. As the evidence preponderates against the claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for a bilateral knee disability is denied. Entitlement to service connection for neurologic and biologic toxicity is denied. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for visual impairment is denied. Entitlement to service connection for a seizure disorder is denied. Entitlement to service connection for Lyme disease is denied. Entitlement to service connection for heavy metal toxicity is denied. Entitlement to service connection for human monocytic ehrlichiosis, to include Ehrlichia, is denied. Entitlement to service connection for chlamydia pneumoniae is denied. Entitlement to service connection for Epstein-Barr virus is denied. Entitlement to service connection for human herpes virus 6 (HHV6) is denied. Entitlement to service connection for herpes simplex virus 1 is denied. Entitlement to service connection for chronic candidiasis is denied. Entitlement to service connection for a disability as a result of a vaccination injury is denied. Entitlement to service connection for immune system inflammation and dysfunction is denied. ______________________________________________ K. Conner Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs