Citation Nr: 1800389 Decision Date: 01/04/18 Archive Date: 01/19/18 DOCKET NO. 10-22 069 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for residuals of parvovirus B19 (fifth's disease) infection, to include arthropathy, tendonitis, and bursitis of the bilateral shoulders, hands, wrists, hips, knees, ankles, neck, and lower back. 2. Entitlement to service connection for Eustachian tube dysfunction. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD P. M. Johnson, Counsel INTRODUCTION The Veteran had active military service from February 1990 to September 1997; he also reportedly had four 45-day periods of prior active duty service. This matter comes to the Board of Veterans' Appeals (Board) from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio in October 2008. The Veteran testified before the undersigned Veterans Law Judge at a Board Central Office hearing in May 2011. In May 2013, the Board, in pertinent part, remanded the issues of service connection for residuals of parvovirus B19 infection and service connection for Eustachian tube dysfunction for additional development. The Board also remanded the issue of entitlement to a rating higher than 50 percent for migraine headaches in accordance with Manlincon v. West, 12 Vet. App. 238 (1999). Following the remand, in August 2016, the RO issued a statement of the case (SOC) as to the claim for a higher rating for migraines. Neither the Veteran, nor his representative responded to the SOC and the claim became final. Accordingly, entitlement to a higher initial rating for migraine headaches is not currently before the Board. FINDINGS OF FACT 1. The Veteran was diagnosed with parvovirus B19 infection in June 1993 during active service. 2. At separation from service in July 1997, the Veteran was reported to have defects that included "arthralgias of multiple joints" and joint effusion of the left wrist and left shoulder. 3. The Veteran reports recurrent symptoms of stiffness of his bilateral shoulders, hands, wrists, hips, knees, ankles, neck, and lower back since being diagnosed with parvovirus B19 infection in service. 4. The Veteran was diagnosed with Eustachian tube dysfunction in July 1993. 5. The Veteran reports recurrent symptoms of intermittent fullness in his ears since his period of active service. CONCLUSIONS OF LAW 1. Residuals of parvovirus B19 infection, to include arthropathy, tendonitis, and bursitis of the bilateral shoulders, hands, wrists, hips, knees, ankles, neck, and lower back were incurred in active service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 2. Eustachian tube dysfunction is due to the Veteran's active service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service Connection, Generally Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303 (a) (2017). Service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303 (d). In February 2008, the Veteran filed a claim for service connection for the residuals of a parvovirus B19 infection and Eustachian tube dysfunction. The Veteran stated that both conditions began during his period of active service and have persisted since that time. Parvovirus B19 Infection The Veteran's service medical records confirm that the Veteran suffered from a parvovirus B19 infection in June 1993. The claims file indicates that the Veteran initially suffered from symptoms that included malaise, a rash, and severe arthralgia as a result of the infection. While the Veteran reports that a majority of his symptoms resolved within a few weeks, he states that he has had residual arthropathy, tendonitis, and bursitis of the bilateral shoulders, hands, wrists, hips, knees, ankles, neck, and lower back. After review of the evidence of record, the Board finds that the residuals of the parvovirus B19 infection, were incurred during his period of active service and service connection is warranted. In addition to the Veteran's treatment related to the parvovirus B19 infection in June 1993, his STRs indicate that the Veteran sought treatment for persistent stiffness in the ankles, knees, and back in December 1994. Further, in his "Report of Medical History" at separation from service the Veteran noted neck stiffness and the examiner stated that the Veteran had been diagnosed with fifth's disease in 1993 that was complicated by persistent morning stiffness. The Veteran's separation examination in 1997 also reported defects of "arthralgias of multiple joints" and indicated tenderness and effusion of the left wrist and left AC joint. In March 2008, the Veteran provided a description of his condition. He stated that he had developed chronic, migratory polyarthritis, bursitis, and tendonitis following his infection, which is a less common result of fifth's disease. He stated, "I have continued to suffer symptoms of arthritis and at times severe morning 'gelling' involving my back, hips, knees, ankles, and hand joints, all of which I continue to treat symptomatically with NSAIDS since contracting this infection." In June 2008, a VA examiner provided an opinion regarding the etiology of the Veteran's arthralgia. "In my opinion, it is less likely the Veteran's chronic arthropathy is secondary to his diagnosis of parvovirus B19 infection. According to the Veteran's service medical records, the Veteran was diagnosed with parvovirus B19 infection in 1993. According to UpToDate, the parvovirus B19 infection can present as an acute arthritis. Joint symptoms usually resolve in three weeks, although a minority of patients develop persistent or recurring arthropathy." In August 2016, another medical opinion regarding the etiology of the Veteran's arthralgia was obtained. The examiner opined that the condition claimed was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner stated that "adult variant-parvovirus B19 infection was diagnosed on June 7, 1993 during active military service. People with fifth's disease can also develop pain and swelling in their joints (polyarthropathy syndrome) usually in the hands, feet, or knees, and no other symptoms. The joint pain usually lasts 1 to 3 weeks, but it can last for months or longer. It usually goes away without any long-term problems. As per UpToDate: Joint symptoms with parvovirus B19 are usually acute and symmetric, and most frequently involve the small joints of the hands, wrists, knees, and feet. Joint stiffness is common... Joint symptoms usually resolve in three weeks, although a minority of patients may develop persistent or recurring arthropathy." In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry: (1) determining the competency of the source; (2) determining credibility, or worthiness of belief, and (3) weighing its probative value. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007); Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). The Board notes that the Veteran is competent to testify as to his perceived symptoms, such as his complaints of pain. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Typically, a Veteran is not competent to provide a diagnosis of complex medical condition, however, the Veteran is a medical doctor; accordingly, his opinions will be afforded the weight of a medical professional. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Here, the Board finds that the evidence of record is at least in equipoise regarding whether the Veteran's arthropathy is due to his in-service parvovirus B19 infection. The Board notes that the Veteran has repeatedly opined that his arthralgia is the result of the residuals of his parvovirus B19 infection. He has credibly reported recurrent joint stiffness, particularly in the morning, since his June 1993 infection. The Board finds that the opinion of the Veteran to be of greater probative value, as the Veteran has applied the facts of his situation to his particular claim. The Veteran has noted the temporal relationship between the onset of his arthralgia and his diagnosis of parvovirus B19 infection. He has also noted his repeated documented complaints during service, particularly the defects reported by the medical examiner at separation that included "arthralgias of multiple joints" and the tenderness and effusion of the left wrist and left AC joint recorded at that time. The Board finds the opinion of the Veteran to be of greater probative weight than the VA examiners as these opinions appear to be primarily based upon the statistical likelihood of long-term arthralgia due to parvovirus B19 infection. Both the 2008 and 2016 examiners note the UpToDate report that parvovirus B19 infection can cause joint symptoms that usually resolve in three weeks; however, both examiners note that UpToDate specifically warns that "a minority of patients may develop persistent or recurring arthropathy." Both examiners dismiss the Veteran's reports that he suffers from recurring arthropathy since his period of service and fail to discuss the Veterans documented joint issues at separation from service. As the Veteran's medical opinion is the only opinion of record that accounts for the Veteran's credible post-service reports of recurrent joint pain (as well as the reports of recurrent joint pain at separation from service), the Board finds that the weight of the probative evidence of record supports the Veteran's claim for service connection for the residuals of parvovirus B19 infection. As the evidence of record is at least in equipoise regarding whether the Veteran's joint pain is the result of residuals of parvovirus B19 infection, the Board finds that service connection for the residuals of parvovirus B19 infection is warranted. 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Eustachian Tube Dysfunction The Veteran has also reported the onset of Eustachian tube dysfunction during service and that it has continued to persist on a recurrent basis since that time. The Veteran's service treatment records note that he was provided treatment for Eustachian tube dysfunction in July 1993. Treatment records from May 1994 note, though, that this condition had resolved. The Veteran, however, has argued that while the condition may temporarily resolve, either on its own or through medications that this is chronic condition that has repeatedly recurred since his in-service diagnosis. During the Veteran's Board hearing, it was noted that this condition is periodic and not continuous. The Veteran stated "It's pretty frequent. It will happen once or twice a week where I get stopped up and can't clear my ears. Sometimes, I actually can hear fluid kind of sloshing around in my head." The Board notes that the Veteran's service treatment records state that the Veteran was sent to an ENT in June 1997 for an audio evaluation due to recent problems with Eustachian tube dysfunction. The examiner at the Veteran's separation from service also noted that the Veteran was on profile related to his Eustachian tube dysfunction and that his last infection had been in June 1997. In June 2008, the Veteran was sent for a VA examination regarding his Eustachian tube dysfunction. The Veteran reported intermittent fullness in his ears. The examiner stated that he could not comment on his Eustachian tube dysfunction as he did not have a tympanogram to view in order to assess middle ear function. The Veteran was provided another examination in July 2016. The examiner diagnosed the Veteran with Eustachian tube dysfunction, resolved (recurring). The examiner opined that the Veteran's condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner stated that the Veteran was diagnosed with Eustachian tube dysfunction during service but it resolved without any residual. The examiner stated that the Veteran reported that the condition continues to recur, but the examiner states that "it is the nature of this condition." Upon review of the evidence of record, the Board finds that the evidence of record weighs in support of the Veteran's claim for service connection. The 2016 examiner indicates that the Veteran has a diagnosis of recurring Eustachian tube dysfunction. The examiner states that it is the nature of this condition to resolve for a period of time and then recur. The evidence is clear that the Veteran had multiple instances of this condition during his period of service, and he has provided credible statements that it has continued to recur since his period of service. As the 2016 examiner has provided evidence of a diagnosis of Eustachian tube dysfunction during the appeal period and the Veteran has provided evidence of a nexus between this recurring condition and his period of active service, the Board finds that the weight of the probative evidence of record supports the Veteran's claim for service connection for Eustachian tube dysfunction. Accordingly, the Board finds that service connection for Eustachian tube dysfunction is warranted. 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to service connection for residuals of parvovirus B19 infection, to include arthropathy, tendonitis, and bursitis of the bilateral shoulders, hands, wrists, hips, knees, and ankles, neck, and lower back is granted, subject to the regulations governing the award of monetary benefits. Entitlement to service connection for Eustachian tube dysfunction is granted, subject to the regulations governing the award of monetary benefits. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs