Citation Nr: 18149104 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 14-28 319A DATE: November 8, 2018 ORDER Entitlement to service connection for left hip degenerative joint disorder to include as secondary to service connected meningococcal meningitis is denied. Entitlement to service connection for right hip degenerative joint disease to include as secondary to service connected meningococcal meningitis is denied. Entitlement to service connection for degenerative disc disease of the lumbar spine to include as secondary to service connected meningococcal meningitis is denied. Entitlement to service connection for diabetes mellitus (DMII) to include as secondary to service connected meningococcal meningitis is denied. FINDINGS OF FACT 1. The Veteran’s left hip degenerative joint disorder is not related to service, and was not caused or aggravated by service connected meningococcal meningitis. 2. The Veteran’s right hip degenerative joint disorder is not related to service, and was not caused or aggravated by service connected meningococcal meningitis. 3. The Veteran’s lumbar spine degenerative disc disease is not related to service, and was not caused or aggravated by service connected meningococcal meningitis. 4. The Veteran’s DMII is not related to service, and was not caused or aggravated by service connected meningococcal meningitis. CONCLUSIONS OF LAW 1. The criteria for service connection for left hip degenerative joint disease, to include as secondary to meningococcal meningitis, are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310. 2. The criteria for service connection for right hip degenerative joint disease, to include as secondary to meningococcal meningitis, are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310. 3. The criteria for service connection for degenerative disc disease of the lumbar spine, to include as secondary to meningococcal meningitis, are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310. 4. The criteria for service connection for DMII, to include as secondary to meningococcal meningitis, are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1970 to December 1970. This case comes before the Board of Veterans’ Appeals (Board) on appeal of an June 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota which among other things denied service connection for degenerative disc disease of the lumbar spine, degenerative joint disease of the left hip, degenerative joint disease of the right hip, and DMII, all of which were claimed as secondary to residuals of service-connected meningococcal meningitis. The Veteran submitted his notice of disagreement in June 2013, and in August 2014 was issued a statement of the case and perfected his appeal to the Board. In an April 2018 decision, the Board remanded the issues currently on appeal for an addendum medical opinion to consider medical treatise information submitted by the Veteran’s attorney which was provided in May 2018. For the reasons indicated in the discussion below, the opinion obtained was adequate and the AOJ therefore substantially complied with the Board’s remand instructions. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268 (1998)) violation when the examiner made the ultimate determination required by the Board’s remand). Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from a disease or injury incurred in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service incurrence of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, including arthritis and DMII, may be presumed to have been incurred in, or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309(a). Service connection is also warranted for disability proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (b). 1. Entitlement to service connection for left and right hip degenerative joint disorder, and degenerative disc disease of the lumbar spine, to include as secondary to service connected meningococcal meningitis The Veteran contends that he is entitled to service connection for left and right hip degenerative joint disease and degenerative disc disease of the lumbar spine, to include as secondary to residuals of meningococcal meningitis. The Veteran’s December 1970 separation examination report was normal and his service treatment records do not note any complaints or treatment for left or right hip degenerative joint disease, or degenerative disc disease of the lumbar spine. In a June 2012 disability benefits questionnaire (DBQ), the Veteran reported that his hips hurt “a lot” and his legs “ache” and have for several years. He denied a history of trauma to his hips or legs while in service or after service. The examiner noted no evidence of bilateral hip degenerative joint disease in the Veteran’s service treatment records and stated it was less likely than not proximately due to or the result of the Veteran’s service-connected spinal meningitis. The examiner opined that the bilateral hip degenerative joint disease was the result of the normal aging process and noted that it was not aggravated beyond its natural progression by spinal meningitis as no medical evidence or objective findings support that residuals of spinal meningitis exist. The June 2012 examiner also noted that the Veteran reported that his lower back hurt “a lot” and has for several years. The Veteran had not sought care for his back condition and had not been diagnosed for a back condition. He denied a history of trauma to the back while in service or after service. The examiner found no evidence of degenerative disc disease of the lumbosacral spine in the Veteran’s service treatment records and opined that the Veteran’s lumbosacral spine degenerative disc disease was less likely than not proximately due to or the result of the Veteran’s service connected meningococcal meningitis. The examiner indicated that the Veteran’s lumbosacral spine degenerative disc disease is the result of the normal aging process and not related to his spinal meningitis diagnosis in 1970. The examiner also indicated that there was no medical evidence or objective findings to support that residuals of spinal meningitis exist. In addition, the examiner found that lumbosacral spine degenerative disc disease was not aggravated beyond its natural progression by spinal meningitis. The Veteran’s attorney submitted an article from The National Center for Biotechnology Information website in August 2014 which reported a wide and varied range of potential long-term sequelae following meningitis and meningococcal disease. The article noted that some sequelae may not become apparent until months or years after the acute illness and indicated bone and joint complications are among the potential morbidities following meningococcal disease. In a May 2018 medical opinion, the examiner indicated that the Veteran’s right and left hip degenerative joint disease was less likely than not proximately due to or the result of his service connected meningococcal meningitis. The examiner stated that after review of the claims file including submitted medical treatise documentation, there was no evidence linking meningococcal meningitis to the development of degenerative joint disease of the left and right hip. The examiner stated that the development of such disease is most likely the result of the normal aging process and the Veteran’s occupations since active duty service. The examiner indicated that there was no evidence to support aggravation beyond natural progression and noted that according to relevant medical treatise documentation, degenerative joint disease of the hips results from a complex interplay of multiple factors, including joint integrity, genetics, local inflammation, mechanical forces, and cellular and biochemical processes. Known risk factors were noted to include age, obesity, occupation, previous injury, and genetic elements. The examiner concluded that there is no nexus between degenerative joint disease of the left and right hip and meningococcal meningitis. The May 2018 addendum medical opinion report also indicated that the Veteran’s degenerative disc disease of the lumbar spine was less likely than not proximately due to or the result of the Veteran’s service connected meningococcal meningitis. The examiner noted that after review of the claims file including medical literature regarding meningococcal meningitis and its complications, there was no medical evidence linking meningococcal meningitis to the development of degenerative disc disease of the lumbar spine. The examiner stated the development of degenerative disc disease of the lumbar spine was most likely the result of the normal aging process and the occupations since active duty service. He indicated that there was no evidence to support aggravation beyond natural progression. The examiner noted that according to the medical resource UpToDate, degenerative disc disease of the spine results from a complex interplay of multiple factors, including joint integrity, genetics, local inflammation, mechanical forces, and cellular and biochemical processes. The examiner found no nexus between degenerative disc disease of the lumbar spine and meningococcal meningitis. In October 2018 the Veteran’s attorney submitted an additional article from BioMed Central which noted that arthritis is a common manifestation in patients with community-acquired bacterial meningitis. The preponderance of the evidence is against the Veteran’s claim for service connection on both a direct and secondary basis. The Veteran’s service treatment records do not note complaints of or treatment for left and right hip degenerative joint disease in service, and the Veteran’s medical examination report upon discharge from service is normal. The Veteran does not contend that he suffered an injury, disability or disease in service which caused his left and right hip degenerative joint disease or degenerative disc disease of the lumbar spine. There is no evidence that the Veteran’s left and right hip degenerative joint disease or lumbar spine degenerative disc disease manifested to a compensable degree within a year after discharge from service, therefore service connection as a chronic disease is not warranted. The May 2018 examiner opined that the Veteran’s left and right hip degenerative joint disease was less likely than not proximately due to, the result of, or aggravated by his service connected meningococcal meningitis and provided a sufficient rationale to support her findings after a thorough examination, and reviewing the claims file. Thus, the examiner’s opinion is afforded considerable probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The Board must weigh this opinion against the medical literature submitted by the Veteran. The Court has indicated that treatise evidence may suffice to establish nexus in instances where “standing alone, [it] discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion.” Sacks v. West, 11 Vet. App. 314, 317 (1998). Significantly however, the Court has also held that treatise materials generally are not specific enough to show nexus, Id. at 317, and that medical opinions directed at specific patients generally are more probative than medical treatises. Herlehy v. Brown, 4 Vet. App. 122, 123 (1993). In this case, the above described reasoned opinion by the physician specifically indicating a lack of causation or aggravation is of greater probative weight than the medical literature submitted by the Veteran indicating generally that meningitis and meningococcal disease can cause arthritis and bone and joint complications. The Board has considered the Veteran’s contentions that his left and right hip degenerative joint disease is a result of his service connected meningococcal meningitis. Lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran’s particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The issue of whether meningococcal meningitis can cause or aggravate a left and right hip degenerative joint disease case is a complex medical issue that goes beyond a simple and immediately observable cause-and-effect relationship. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Veteran’s statements in this regard are therefore not competent. The Board also acknowledges the Veteran’s attorney’s request for a new VA examination to specifically address why the Veteran’s conditions could not be related to his in-service meningitis. However, the Board has reviewed the May 2018 VA examination report and finds that it is adequate for adjudication purposes, thus a remand for additional clarification is unnecessary. It reflects that the examiner fully examined the Veteran, reviewed his claims file and his history regarding his symptom manifestations and provided a full analysis regarding the etiology of his right and left hip degenerative joint disease, and degenerative disc disease of the lumbar spine. Thus, the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). For the foregoing reasons, the criteria required for service connection for left and right hip degenerative joint disease and lumbar spine degenerative disc disease, to include as secondary to the service-connected meningococcal meningitis, have not been met. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for diabetes mellitus (DMII) to include as secondary to service connected Meningococcal meningitis The Veteran contends that he is entitled to service connection for DMII to include as secondary to residuals of meningococcal meningitis. The Veteran’s service treatment records do not note any treatment or diagnosis for DMII in service and his December 1970 medical examination report upon discharge is normal. In a June 2012 VA examination note, the examiner noted no evidence of DMII in the Veteran’s service treatment records and stated the DMII diagnosis is less likely than not proximately due to or the result of his in-service diagnosis of spinal meningitis. The examiner noted the Veteran was diagnosed with spinal meningitis in 1970 and DMII in 2000, and stated there is no research to support that a causal relationship exists between spinal meningitis and DMII. The examiner also stated that there is no medical evidence or objective findings to support that residuals of spinal meningitis exist. The examiner concluded that the Veteran’s DMII was not aggravated beyond natural progression by spinal meningitis as there is no medical evidence or objective findings to support that residuals of spinal meningitis exist. In August 2014, the Veteran’s attorney submitted the aforementioned National Center for Biotechnology Information article which reported renal impairment as a potential complication following meningococcal disease. In a May 2018 addendum medical opinion, the examiner opined that the Veteran’s DMII was less likely than not proximately due to or the result of the Veteran’s service connected meningococcal meningitis. The examiner stated that after review of the claims file including submitted medical treatise literature, there is no medical evidence to link meningococcal meningitis to the development of DMII. The examiner also indicated that there was no evidence to support aggravation beyond natural progression. The examiner referred to medical literature from UpToDate which noted DMII is characterized by hyperglycemia, insulin resistance, and relative impairment in insulin secretion, and that it is a common disorder with a prevalence that rises markedly with increasing degrees of obesity. The examiner opined that the most likely cause of the Veteran’s DMII was obesity with body mass index greater than 30 and age, and that there was no nexus of development of DMII to meningococcal meningitis. The preponderance of the evidence is against the Veteran’s service connection claim for DMII to include as due to service-connected meningococcal meningitis. The evidence in support of the claim is limited to the Veteran’s general contention and the medical treatise submitted by the Veteran’s attorney. There is no evidence of treatment for, or a diagnosis of DMII in service, and the Veteran does not assert a continuity of symptomatology nor is it suggested by the evidence of record. Therefore, neither the lay nor medical evidence suggest that DMII manifested in service or within the one-year presumptive period for chronic diseases. The issue of establishing a nexus to service or service-connected disease or injury for post-service DMII is a complex medical question since it is beyond any readily observable cause and effect relationship. Jandreau, 492 F.3d at 1377, n. 4. Thus, to the extent the Veteran asserts a nexus for post service DMII, his statements in this regard are not competent. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). The record contains a negative nexus opinion and a negative addendum opinion provided by a VA examiner stating that the Veteran’s DMII was less likely than not proximately due to or the result of the Veteran’s service connected meningococcal meningitis and there is no positive nexus opinion of record. As the examiner explained the reasons for her conclusions that the Veteran’s DMII is not related to his service connected meningococcal meningitis based on an accurate characterization of the evidence of record, her opinions are entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. 295, 304 (2008). Weighing this opinion against the medical literature submitted by the Veteran’s attorney, the physician’s opinion specifically indicating a lack of causation or aggravation in this case is of greater probative weight than the medical literature submitted by the Veteran indicating generally that meningitis and meningococcal disease can cause renal impairment. For the above stated reasons, the preponderance of the evidence weighs against a relationship between DMII and service or a service connected disease or injury, therefore service connection for DMII is not warranted. As the preponderance of the evidence is 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. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Maddox, Associate Counsel